Nursing needs less compassion: my first response to the Francis report

I’ve not got through the full Francis report yet, but three recommendations I’ve seen so far strike me as stupid.

1) Recommendations 74-78 are about increasing the responsibilities of NHS Trust Foundation governors very signficantly, around ensuring that healthcare standards are met and accountability to the wider public over and above the Foundation membership, and public profile.

This is simply demanding too much of unpaid governors, who have often come into the role with a eye to reflecting the wider public’s wishes about service delivery, rather than being held accountable for delivery failure. This is, and should remain, the role of paid non-executive directors, who gain barely a mention in the recommendations. These are the people with the expertise and time to scrutinise healthcare standards, and the remuneration to match, yet they are now to have their backs covered by people with less time and less expertise. Bizarre. Many FT governors will simply resign if faced with these new duties, and Trusts currently going through the foundation application process with Monitor will find recruitment nigh on impossible.

2) Recommendation 201 is:

The Royal College of Nursing should consider whether it should formally divide its “Royal College” functions and its employee representative/trade union functions between two bodies rather than behind internal “Chinese walls”.

First of all, it is quite bizarre that Francis apparently entirely forgets about the other main nursing union, UNISON, in his recommendations. Second, Francis fails to see what trade unions are about, or at least what the should be about. The whole ‘Royal College” function of maintaining standards in the nursing profession should be an integral part of what a trade union does. Ensuring that nurses get to work in a safe, respectful environment requires ensuring that they also get to practice their profession as they should. Quality of work is a basic term and condition, and trade unions have a key role not just in ensuring that management/government live up to their side of the bargain but also in fostering (gild-like) pride in the quality of work. The reason the Winterbourne abuse happened is not primarily because of exploitation by private equity, though that helped create the environment for it. The main reason was that staff weren’t united by professional pride.

To make a false divide between terms of pay/hours and terms of working conditions is very stupid, because it diminishes the potential for trade unions to be part of the solution. In the end it’s those who do the work that have most impact on the quality of their work, not the managers and governors.

3) Recommendation 185 is:

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory.

The report is littered with the casual reference to the virtue of ‘compassion’ in care. Yet the whole concept is essentialism nonsense. The idea that some vague Judaeo-Christian notion of “suffering with” people should be the main driver for a modern public service is bizarre. No-one even really knows what it means.

Frankly, nursing could do with a good deal less compassion, and a great deal more advocacy (co-productive advocacy if you want to get technical). Good advocacy – the capacity to work with patients to negotiate physical, emotional and social changes on their own terms – is a high level function, and can be broken down into sub-categories of knowledge and skill e.g. interpersonal communication, negotiation, systems knowledge as well as making dressing comfortable, ensuring hydration etc..

And of course the link between membership of high quality trade unions and being a good advocate for patients is clear. Getting enough to drink in hospital is a political issue.

This is what nurses should be doing, and how they should be perceived by the policymakers, not fluffing up pillows pointlessly and getting an extra tick for the manner of their ‘there, there, dear.’ Fucking hell, it’s like Lipsky never wrote his stuff.

Sadly, Francis looks to have missed all the real stuff about how to do good work, in favour of improvements to systems which will only fail if the workers are not up for the job. I hope Labour’s reading this as it readies its response.

I I haven’t had time to more than very lightly skim the report – but I think syzygysue points to something Francis mentions, but does nothing much with: the financial pressures put on individual trusts. This gets lost in all the talk about overall NHS spending, but it seems to me no accident that this happened in a struggling Trust with no extra income sources (research, etc.) that was trying to become a Foundation Trust.

I get the sense that Francis wants to blame the board for the FT bid, but the reality is there’s a huge amount of government pressure on boards to go for FT status. We do a disservice if we sweep this under the carpet.

Finally of course, I’m not sure Francis has shown enough courage about targets… but that’s par for the course. The evidence that targets create some very bad situations is widespread, but no-one wants to face up to it.

Weird jargon. Nurses used to be just that nurses. Not some sort of trade union storm trouper.
The purpose of hospital is healing and the easing of suffering.
Not being good unionists and not regardiong the customers as an annoying burdon.
And for that matter not as a diversity enforcement centre either.